Cognitive Impairment (Delirium)

Question 1

What is delirium according to the DSM-5? (4)

Answer 1

1. Acute onset
2. Disturbances in attention, awareness, and cognition
3. Fluctuates in severity
4. Attributable to an underlying cause

Question 2

Delirium is an _____ ___________ state

Answer 2

acute confusional

Question 3

What are 3 other features of delirium?

Answer 3

1. Psychomotor disturbance
2. Altered sleep-wake cycle
3. Emotional lability

Question 4

What is the significance of delirium? (4)

Answer 4

1. Poor prognostic indicator
2. Delirium is associated with:
   - 2x increased risk of death
   - 2.5x increased risk of discharge to higher level of care
   - 12.5x increased risk of developing dementia
3. Increased length of hospitalization (5-10 days)
4. Sustained functional decline 6 months after admission

Question 5

What underlying vulnerabilities can cause delirium? (4)

Answer 5

1. Cognitive dysfunction
2. Frailty
3. Age
4. Stressor(s)
   - Hypoxia
   - Infection
   - Drugs
   - Pain
   - Hypoglycemia
   - Dehydration

Question 6

What are some predisposing factors of delirium? (5)

Answer 6

1. Increased age
2. Dementia
3. Functional impairment (baseline)
4. Multimorbidity
5. Others
   - Decreased vision and/or hearing
   - Mild cognitive impairment
   - Depression
   - Alcohol or drug use/withdrawal

Question 7

What are some precipitating factors of delirium? (7)

Answer 7

1. DRUGS
2. Surgery/trauma
3. Pain
4. Anemia
5. Infection
6. Exacerbation of chronic illness
7. Bedridden

Question 8

What are the worst drugs in terms of causing delirium? (3 groups)

Answer 8

1. Anticholinergics
   - TCAs
   - 1st gen antihistamines
   - 1st gen antipsychotics
   - Muscle relaxants
   - Antimuscarinics
   - Benztropine
2. BZDs/Z-Drugs
3. Opioids

Question 9

What are the bad, but not worst drugs in terms of causing delirium? (4 groups)

Answer 9

1. Anticonvulsants
   - Carbamazepine
   - Phenytoin
   - Topiramate
   - Gabapentin/pregabalin
2. Dopamine agonists
3. Amantadine
4. Cannabis (THC/dose-related)

Question 10

What drugs are less likely but can still possibly cause delirium? (4)

Answer 10

1. Corticosteroids
2. Psychoactive NSAIDs
3. Digoxin
4. Cannabis (CBD-based)

Question 11

What is the most useful bedside tool used for diagnosing delirium?

Answer 11

Confusion Assessment Method (CAM)

Question 12

The confusion assessment method (CAM) requires 1+2 with either 3 or 4. List 1 through 4 symptoms on the list

Answer 12

1. Acute change in mental status with fluctuations
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

Question 13

What are the 3 delirium subtypes?

Answer 13

1. Hyperactive delirium
2. Mixed delirium
3. Hypoactive delirium

Question 14

What are the general symptoms of hyperactive delirium? (3)

Answer 14

1. Combative
2. Agitated
3. Restless

Question 15

What are the general symptoms of hypoactive delirium? (3)

Answer 15

1. Drowsy
2. Somnolent
3. Unarousable

Question 16

Delirium vs. Dementia: Onset

Answer 16

Delirium - acute (hours-days)
Dementia - chronic (months)

Question 17

Delirium vs. Dementia: Course

Answer 17

Delirium - fluctuating
Dementia - slowly progressive

Question 18

Delirium vs. Dementia: Decreased level of consciousness

Answer 18

Delirium - may be present
Dementia - absent

Question 19

Delirium vs. Dementia: Attention

Answer 19

Delirium - impaired
Dementia - preserved until end-stage

Question 20

Delirium vs. Dementia: Hallucinations

Answer 20

Delirium - common
Dementia - rare until later stages

Question 21

What are 4 strategies to help prevent delirium?

Answer 21

1. Orientation
2. Mobilization
3. Medication review
4. Hydration and nutrition

Question 22

Give examples of orientation in terms of preventing delirium (4)

Answer 22

1. Use calendars, clocks
2. Encourage use of glasses, hearing aids
3. Accommodate visitors
4. Promote regular sleep-wake cycle

Question 23

Give examples of mobilization in terms of preventing delirium (2)

Answer 23

1. Physical therapy
2. Avoid unnecessary lines, catheters, restraints

Question 24

Give examples of medication review in terms of preventing delirium (3)

Answer 24

1. Reassess use of high-risk meds
2. Medication/substance withdrawal?
3. Pain control, bowel + bladder function

Question 25

Give examples of hydration and nutrition in terms of preventing delirium (1)

Answer 25

Maintain or optimize

Question 26

What is the hierarchy of methods to manage delirium? (3)

Answer 26

Base of the pyramid = identify and manage underlying causes Middle = initiate or continue supportive strategies Top = medication only if necessary

Question 27

When it comes to identifying and managing underlying cause(s) of delirium, what are some categories to be looking out for? (9)

Answer 27

1. Readily reversible causes - e.g., hypoglycemia 2. Infection 3. Neurologic 4. Medication-induced adverse effects, intentional or unintentional overdose, supratherapeutic levels because of renal or liver disease 5. Toxicologic 6. Metabolic 7. Cardiopulmonary 8. Environmental factors 9. Other factors

Question 28

What are some examples of providing supportive care for delirium management? (7)

Answer 28

1. Treat the underlying condition 2. Manage pain and other symptoms 3. Encourage mobilization 4. Re-orientation cues 5. Maintain sleep-wake schedule 6. De-escalation for agitated individuals 7. System-level interventions: - Minimize time spent in ER - Trained volunteers to calm, provide re-orientation - Low beds - Non-slip floors or socks

Question 29

We do pharmacological management of delirium ONLY IF: (3)

Answer 29

1. The patient is in significant distress from their symptoms 2. The patient poses a safety risk to self or others 3. The patient is impeding essential aspects of medical care

Question 30

What is first line in pharmacological management of delirium?

Answer 30

Antipsychotics - Similar efficacy among agents - Choice based on side effect profile, patient factors, availability - Start with low doses and titrate to effect ~q30min - Prn doses thereafter

Question 31

What group of meds should be avoided in delirium management? (What is the exception)

Answer 31

Avoid benzos - Except in alcohol-withdrawal delirium, terminal delirium

Question 32

The conventional drug of choice for delirium management is?

Answer 32

Haloperidol - Note: if longer treatment duration is required, switch to atypical to reduce risk for EPS

Question 33

Of the atypical antipsychotics, which is most anticholinergic?

Answer 33

Olanzapine

Question 34

Which atypical AP is the agent of choice for individuals with Parkinson's disease or Lewy Body Dementia?

Answer 34

Quetiapine

Question 35

Degree of sedation for the following: Haloperidol Risperidone Olanzapine Quetiapine

Answer 35

Haloperidol - low Risperidone - low Olanzapine - moderate Quetiapine - high

Question 36

Risk of EPS for the following: Haloperidol Risperidone Olanzapine Quetiapine

Answer 36

Haloperidol - high Risperidone - high Olanzapine - moderate Quetiapine - low

Question 37

Adverse effects for the following: Haloperidol Risperidone Olanzapine Quetiapine

Answer 37

Haloperidol - risk of EPS increases if daily dose exceeds 3mg Risperidone - slightly less risk of EPS than with haloperidol at low doses Olanzapine - more sedating than haloperidol Quetiapine - much more sedating than haloperidol; risk of hypotension

Question 38

Atypical APs have a black-box warning for use in individuals with dementia. What is that warning?

Answer 38

Increased risk of mortality (~1.6x) - Not seen in studies of short-term use for delirium (3-7 days)

Question 39

What is the role of the pharmacist in delirium prevention and management? (3)

Answer 39

1. Deprescribe medications known to increase delirium risk 2. Assess for and manage pain, constipation 3. Ensure judicious use of antipsychotics for delirium - >=25% of APs started in hospital are continued after discharge